Type of LAA Exclusion and Homeostasis

Study Questions:

What is the impact of left atrial closure on homeostasis using epicardial or endocardial left atrial appendage (LAA) devices?

Methods:

This was a single-center, prospective, observational study evaluating 77 patients who underwent LAA closure using an epicardial (n = 38) or endocardial device (n = 39). Hormones involved in the adrenergic (adrenaline, noradrenalin) renin-angiotensin-aldosterone system (aldosterone, renin), metabolic (adiponectin, free fatty acids, insulin, β-hydroxybutyrate, and free glycerols), and natriuresis (atrial and B-type natriuretic peptides) were assessed before the procedure, after device deployment, after 24 hours, and after 3 months.

Results:

Most of the changes noted were in the epicardial LAA group. This included significantly lower adrenaline, noradrenaline, and aldosterone levels at 24 hours and 3 months (p < 0.05) compared to baseline. In addition, there were significant increases in adiponectin and insulin, with decreased free fatty acids at 3 months. N-terminal pro-A-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide were significantly decreased in the acute phase after epicardial LAA device implantation, which subsequently normalized at 3 months. There was no significant change in hormone levels in the endocardial LAA group. Systemic blood pressure was also significantly lower at all time points after epicardial LAA device implantation, which was not seen post–endocardial LAA device implantation.

Conclusions:

There are substantial differences in hemodynamics and neurohormonal effects of LAA exclusion with epicardial and endocardial devices. Further studies are required to elucidate the underlying mechanism and clinical relevance of these physiological changes.

Perspective:

This study attempts to better understand the complex interaction between the LAA and hormonal regulation. A major limitation is sizable numerical differences in baseline levels of measured hormones between the epicardial and endocardial LAA groups, suggesting heterogeneity in the treatment groups. With that in mind, it does appear the LAA exclusion using the epicardial approach impacts homeostasis more than the endocardial approach. This will need to be confirmed in a larger cohort of patients prior to ascertaining associated clinical relevance, if any.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Heart Failure and Cardiac Biomarkers, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Adiponectin, Adrenergic Agents, Aldosterone, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Blood Pressure, Endocardium, Epinephrine, Fatty Acids, Glycerol, Heart Atria, Homeostasis, Hydroxybutyrates, Insulin, Natriuresis, Natriuretic Peptide, Brain, Natriuretic Peptides, Norepinephrine, Peptide Fragments, Renin-Angiotensin System, Angiography


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